NDVA - SFN 54412 Request for Release of Private Data

Name of County Recorder/Veterans Service Officer or ND Department of Veterans Affairs Releasing Information
Name of County Recorder/Veterans Service Officer or ND Department of Veterans Affairs Releasing Information
This authorization gives express authority to the County Recorder/Veterans Service Officer or North Dakota Department of Veterans Affairs to release a copy of the DD 214, or other private data held by the department of veteran identified in this release.

Provision of State Data Practices Act under North Dakota Statute
1. Information collected through use of this release may be used and disseminated only to individuals or agencies specifically authorized access to that data by state, local or federal law subsequent to the collection of that data.
2. You may refuse to sign this release of information, but such refusal will result in a denial of your request for record.
3. This release of information is valid for this request only.
VETERAN'S IDENTIFYING INFORMATION

Note: If the veteran's name has changed since the requested separation document was issued, provide evidence of the name change, such as marriage certificate, divorce decree, court ordered name change, adoption record, etc.
Name of Veteran*
Veteran's Social Security or Service Number*
Date of Birth*

MonthDayYear
Date
Date of Death

MonthDayYear
Date
Date of Entry

MonthDayYear
Date
Date of Separation

MonthDayYear
Date
Branch

DATA ON PERSON REQUESTING INFORMATION
Requester's Name (Last, First, Middle)*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email Address
example@example.com
Relationship to Veteran (in the case of a deceased veteran)*
Do you want these records sent to a specific county or tribal Veterans Service Office?*

YesNo
Which county or tribe?
Signature of Requestor*

Clear
Date*

MonthDayYear
Date
Supporting Documentation

Browse Files
This includes proof of name changes, guardianship, power of attorney, etc. Cancelof
The Veteran's social security number is requested to enable the ND Department of Veterans Affairs to conduct a check for VA Benefits and to verify military service pursuant to N.D.C.C. sections 37-14-01.1 and 37-14-14. The individual's social security number will be used as an identification number. Disclosure of your social security number is mandatory. If you do not provide your social security number, the ND Department of Veterans Affairs will be unable to verify required information and fulfill your request.
Check the box if no action required, VSO records only.

No action required
Please verify that you are human*
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